Why quality improvement evidence based practice and research would be applied in a health care setting?

What is Evidence-Based Practice?

The classic definition of Evidence-Based Practice (EBP) is from Dr David Sackett. EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research”.2

EBP has developed over time to now integrate the best research evidence, clinical expertise, the patient's individual values and circumstances, and the characteristics of the practice in which the health professional works.3

So, EBP is not only about applying the best research evidence to your decision-making, but also using the experience, skills and training that you have as a health professional and taking into account the patient's situation and values (e.g. social support, financial situation), as well as the practice context (e.g. limited funding) in which you are working.  The process of integrating all of this information is known as clinical reasoning.  When you consider all of these four elements in a way that allows you to make decisions about the care of a patient, you are engaging in EBP.4

Why is Evidence-Based Practice Important?

EBP is important because it aims to provide the most effective care that is available, with the aim of improving patient outcomes.  Patients expect to receive the most effective care based on the best available evidence.  EBP promotes an attitude of inquiry in health professionals and starts us thinking about: Why am I doing this in this way?  Is there evidence that can guide me to do this in a more effective way?  As health professionals, part of providing a professional service is ensuring that our practice is informed by the best available evidence.  EBP also plays a role in ensuring that finite health resources are used wisely and that relevant evidence is considered when decisions are made about funding health services.4

What happened before Evidence-Based Practice?

Before EBP health professionals relied on the advice of more experienced colleagues, often taken at face value, their intuition, and on what they were taught as students.  Experience is subject to flaws of bias and what we learn as students can quickly become outdated.  Relying on older, more knowledgeable colleagues as a sole information source can provide dated, biased and incorrect information.  This is not to say that clinical experience is not important - it is in fact part of the definition of EBP.  However, rather than relying on clinical experience alone for decision making, health professionals need to use clinical experience together with other types of evidence-based information.5

Is not all Published Research of Good Quality?

Not all research is of sufficient quality to inform clinical decision making.  Therefore you need to critically appraise evidence before using it to inform your clinical decision making. The three major aspects of evidence that you need to critically appraise are:

• Validity - can you trust it?
• Impact - are the results clinically important?
• Applicability - can you apply it to your patient?

Determining whether a project is evidence-based practice (EBP), quality improvement (QI), or research can be challenging—even for experts! Some projects that appear to be EBP or QI may contain elements of research. Conversely, some projects that we refer to colloquially as research are actually EBP or QI. Finding the correct determination is important for ensuring that projects are reviewed by the appropriate bodies since research projects require Institutional Review Board (IRB) review while EBP and QI projects do not. This guide is designed to clarify the definitions of EBP, QI, and research, and to provide insight into which projects meet the definition of research.

As a reminder, all MSHS nurse-led EBP, QI, and research projects must be reviewed by the Nursing Project Approval Council (NPAC) before they begin. NPAC will determine whether projects meet the definition of research and require IRB review. For more information about NPAC, please see our guide titled The Nursing Project Approval Council (NPAC): Who, What, Where, When, Why, and How to Submit Your Project.

Part I. Definitions and Characteristics of EBP, QI, and Research Projects

Evidence-based Practice

• Asks the question, “Does our current policy, practice, or standard operating procedure reflect the best available evidence?”
• Goal is to find existing research that demonstrates which policy, practice, or procedure is the best known way to produce a specific outcome in a specific population.
• May use the PICO (Population, Intervention, Comparison, Outcome) framework to search the literature.
• If the best practice differs from the organization’s current practice, the organization adopts the best practice and evaluates whether outcomes improve after the change.

Quality Improvement

• Asks the question, “Are we optimally performing our current policy, practice, or procedure when we deliver care?”
• Goal is to improve patient outcomes by methodically identifying areas where performance falls short of the standards set by the organization.
• QI projects use evidence from the literature to implement interventions aimed at improving performance to meet the standard (e.g., staff education, workflow redesign, revised informatics, or communications), and then evaluates whether the intervention improved performance. While patient outcomes may be used as a proxy for or indicator of performance, the goal is to improve the performance of a specific task or process in accordance with institutional policies or standards.

Research

• Research is any systematic investigation designed to contribute to generalizable knowledge. Methods vary depending on the aims of the study.
• Goals may be to describe a phenomenon, develop or test a new method or hypothesis, or evaluate the implementation of a new method.
• Asks a variety of questions such as “Is one policy, practice, or procedure superior to another for achieving an outcome?” or “What are factors and processes that lead to an outcome?”

Part II. Guidance for Differentiating EBP and QI from Research

In partnership with the IRB, the NPAC developed standardized criteria for distinguishing EBP and QI projects from research projects that require IRB review. The criteria and rationale, which are based on federal guidelines and institutional policy, are described below.

1. Intent

The intent of EBP and QI projects is to improve the process of care delivery or implement a new practice standard within the organization. While the proceedings of these projects may be published, the intent of EBP and QI projects is not primarily for publication or dissemination of findings.

The intent of a research project is to generate new knowledge and disseminate findings to the scientific community. While a research study may also have direct benefits to patients in the organization, the primary purpose is advancing knowledge to benefit patients generally.

2. Scope

EBP and QI projects involve the implementation or optimization of care that is already the standard or has already been tested in other environments to demonstrate safety and efficacy.

Projects that implement and evaluate new, modified or adapted practices that have not been tested previously are considered research.

3. Participants and setting

EBP and QI projects are undertaken by staff who normally interact with the population included in the project or are responsible for overseeing quality in the practice area.

Projects that target populations outside the practice or oversight areas of the study team are research.

4. Data collection and storage

EBP, QI, and research projects must take steps to protect data confidentiality. Regardless of the type of project, teams must (1) access only the minimum amount of data required to meet the objective; (2) establish and follow a plan for how the data will be stored and who can access it; (3) and destroy the data after the project and dissemination of findings is complete.

Projects that collect data through intervention (e.g., drawing labs) or interaction (e.g., conducting surveys or focus groups) with the population are research.

5. Benefit

EBP and QI projects must have the potential for direct benefit to the population included in the project.

Research projects may or may not have a potential for direct benefit to the population included in the project.

6. Risk

EBP and QI projects must not introduce risks greater than those associated with the organization’s current policy, practice, or procedure.

Research projects may or may not introduce risks greater than those associated with the organization’s current policy, practice, or procedure. The IRB is responsible for evaluating the level of risk associated with research, ensuring that appropriate measures are in place to reduce risks, and determining whether the level of risk is acceptable in relation to the potential benefits.

7. Methods

In situations where one policy, practice, or procedure is known or suspected, based on evidence, to be superior to another, it is not ethical to assign some people to receive the superior and others to receive the inferior. Since EBP and QI projects implement and optimize policies, practices, or procedures that have already been shown to be superior for achieving an outcome, EBP and QI projects generally will not include randomization or other means of assignment to a control group. EBP and QI projects typically employ a pre-post design to compare outcomes before and after the best policy, practice, or procedure is implemented or optimized.

If there is genuine uncertainty about which policy, practice, or procedure is best, a research project is needed to generate this knowledge. Since the best policy, practice, or procedure is not yet known, it is ethical to assign some individuals to receive one and some to receive another through randomization or other means of assignment to a control group.

Why is research and evidence based practice important in health care?

Why quality improvement is important in healthcare?

How does evidence based practice improve quality of care?

What is the purpose of research and evidence based practice?